Prophylactic Antibiotics After Operative Vaginal Births: The Latest Evidence

This transcript has been edited for clarity.

Hello and welcome. I'm Dr George Lundberg and this is an evidence-based Medscape Medical Minute—or two or three.

Anyone who practices medicine has a problem keeping up with a rapidly changing information landscape and knowing what to read and trust. Fortunately, there are some trustworthy, free sources available to help the reader sort it out. One such source is McMaster University in Hamilton, Ontario, Canada. It has been a focal point for EBM—evidence-based medicine—for decades, since that initiative was pioneered by Dr David Sackett.

McMaster University has a partnership with the open-access DynaMed Plus database, which includes a searchable collection of the best evidence from the 500 top-rated medical journals. It is presented in a format that is easy to read and comprehend, and upon which to clinically act. The database is continually updated, provides links for abstract ratings and topics, and helpfully indicates whether the full-text link is or is not behind a pay wall.

Bacterial infections of a variety of types can complicate maternal birthing, especially if by Cesarean section or operative vaginal birth, meaning the use of forceps, vacuum, or another device. There are supporting data, widespread consensus, and guidelines saying it is common practice to administer prophylactic antibiotics with a Cesarean section birthing. Such evidence, guidelines, and practices have not existed for operative vaginal births.

Nine authors from the United Kingdom, representing the ANODE collaborative group, set out to fill that evidence gap by determining whether antibiotic prophylaxis prevents maternal infection after operative vaginal birth. They performed a blinded, randomized, controlled trial, including more than 1700 women aged 16 or older in each of the treatment groups, at 27 obstetrical units in the UK between March 2016 and June 2018.[1]

All women received a single dose of amoxicillin and clavulanic acid or a saline placebo intravenously within 6 hours after operative vaginal birth at 36 weeks' gestation or later. The primary outcome measure was whether a maternal infection was suspected or confirmed within 6 weeks of delivery, as evidenced by confirmed systemic infection by culture, endometritis, or a new antibiotic prescription for specific indications.

Using an intention-to-treat analytic method, 180 (11%) women in the treatment group and 306 (19%) women in the control group had either a confirmed or suspected infection (risk ratio, 0.58; 95% confidence interval, 0.49-0.69; P < .0001). That is a big statistical and clinical difference. One woman in the placebo group and two in the antibiotic group reported allergic reactions.

This report should reinforce or change practice guidelines and clinical practice. This study and these data are that strong. A single dose of certain IV antibiotics shortly after operative vaginal birth is beneficial. Do it. That's my opinion.

I'm Dr George Lundberg, and this is At Large at Medscape.

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